Prof. Christine Taljaard-Krugell is an associate professor at the North-West University’s (NWU) Centre of Excellence for Nutrition with an interest in public health nutrition.

By Prof. Christine Taljaard-Krugell

South Africa has among the most progressive infant feeding policies in the world. The Tshwane Declaration of 2011, signed by ministers, MECs, traditional leaders, and representatives from the World Health Organization and UNICEF, committed the country to protecting exclusive breastfeeding (EBF) for the first six months of life. The R991 Regulations of 2012 imposed strict marketing restrictions on formula. South African law binds companies and citizens to R991 itself; it does not bind them to the subsequent WHO guidance, much of which has evolved since 2012. The country meets the letter of a decade-old law without necessarily meeting the spirit of where the evidence has since travelled.

Exclusive breastfeeding rates tell a different story. The most recent national figure puts exclusive breastfeeding at six months at 22%. A decade and a half of political commitment has not changed this trajectory in any sustained way.

The standard response has been to strengthen the clinical chain: more lactation counsellors, better-trained community health workers, and expanded breastfeeding support at facility level. These interventions matter, and they address barriers that are very real. But evidence suggests that information and clinical support, while necessary, are not sufficient for many South African mothers. What is often missing is something more basic: time and income.

What breastfeeding delivers, and who pays for it

The benefits of breastfeeding for both mother and child are well established. For infants, breastfeeding reduces the risk of infectious diseases and lowers the likelihood of stunting. For mothers, lactation itself lowers the risk of postpartum haemorrhage, type 2 diabetes and certain cancers. These benefits belong first and foremost to the mother-infant pair, regardless of whether the milk reaches the baby directly at the breast or through other means.

However, some of the benefits of breastfeeding extend far beyond the household. A healthier infant places less strain on public clinics and hospitals. Reduced childhood illness means fewer missed school days and, later in life, improved opportunities for the child and lower costs for the state. Economists refer to this spillover effect as a positive externality – a benefit that flows to society beyond what the individual generating it captures for herself.

The scale of this benefit is considerable. Global nutrition investment models estimate a return of US$35 for every US$1 invested in breastfeeding promotion and support. While this is a population-level estimate rather than a household one, it illustrates just how much value is generated beyond the family itself.

Yet the work required to produce these benefits cannot be outsourced. Even when a partner or family member helps by feeding expressed milk, the mother still has to find the time to express it. The physiological work of lactation cannot be transferred to someone else.

She bears the cost in the form of lost income, reduced mobility and an irreducible, non-transferable labour burden, all while generating benefits that extend to her child, herself and society at large. The question is not whether breastfeeding is good for mothers and children – the evidence is unequivocal. The question is whether mothers who shoulder a burden that partly serves the public should be expected to absorb that cost entirely on their own.

The difference between a choice and a real choice

The Tshwane Declaration committed to extending maternity protection to domestic and farm workers. That was in 2011. In 2026, more than a million women in informal employment remain outside the Unemployment Insurance Fund (UIF) system that enables paid maternity leave.

Research among mothers in low-income settlements in North West Province found that stress was the most commonly cited barrier associated with stopping breastfeeding early. This stress was not abstract. It repeatedly stemmed from food insecurity and uncertainty about how to provide for a child without an income.

Many mothers described decisions to stop breastfeeding not because they doubted its value, but because they were trying to meet basic daily needs.

For mothers in this position, recommendations to exclusively breastfeed for six months become public health messages delivered alongside realities that make compliance extraordinarily difficult.

The distinction between formal and substantive freedom is important here. South Africa has given mothers permission to breastfeed. It has not, for many of them, created the conditions that enable them to do so.

What the evidence says about grants

Any proposal for income support encounters familiar objections: grant money will be wasted on alcohol, create dependency or encourage women to have more children. These claims circulate widely, from within healthcare settings to conversations around weekend braais.

Whether these narratives reflect prejudice or simply gaps in understanding is worth interrogating. What the available evidence consistently shows, however, is a different picture.

Studies have found that Child Support Grant income is used predominantly for food, with no significant expenditure on alcohol or non-essential items. Other research has shown that caregivers use grants purposefully to support child nutrition, even under severe conditions of food insecurity.

The Maternal Support Grant as an enabling condition

South Africa has been discussing a Maternal Support Grant since 2012. The current proposal would provide R560 per month for nine months – six months during pregnancy and three months after birth – to women who fall below the Child Support Grant means threshold.

Economic modelling suggests that such a grant would be highly cost-effective. The Department of Social Development officially adopted the Maternal Support Grant as policy in September 2024, although it is still awaiting Cabinet approval.

A Maternal Support Grant alone will not enable mothers to exclusively breastfeed for six months. It does not address workplace lactation facilities or the shortage of skilled counselling support.

The Western Cape's Khulisa Care pilot, which combines nutritional support with home visits from community health workers trained in breastfeeding counselling, offers a more comprehensive model by linking income support with practical assistance.

What a Maternal Support Grant can do, however, is remove the most fundamental barrier before any of the others become relevant.

A mother who is not forced to choose between breastfeeding and eating is a mother for whom support and counselling can begin to make a difference.

Build what is missing

World Breastfeeding Week 2026, which begins on 1 August, carries the theme "Strengthen what works". The clinical infrastructure deserves that investment.

But South Africa signed declarations, drafted regulations and developed guidelines while leaving the most important underlying condition largely unaddressed: a mother's capacity to absorb the cost of the choice she is being asked to make.

Strengthening what works will not be enough if what is missing is left exactly where it has been since 2011.